Provider Demographics
NPI:1952343808
Name:SHUPE, PHILIP R (DPM)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:SHUPE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2180
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91610-0180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 107
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4163
Practice Address - Country:US
Practice Address - Phone:818-265-1581
Practice Address - Fax:818-265-5103
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2648213ES0103X
CAE2648B213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5167410002Medicare NSC
CA5167410001Medicare NSC
T19218Medicare UPIN
CAE2648BMedicare ID - Type Unspecified
CAE2648AMedicare ID - Type Unspecified